Prevalence of DSM-IV Alcohol Abuse and Dependence: United States, 1992.

For the first time, results are presented on the prevalence of alcohol abuse and dependence in the United States in 1992, according to the most recent psychiatric classification of alcohol-related disorders from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). More than 7 percent of adults surveyed met DSM-IV criteria for 1-year alcohol abuse, alcohol dependence, or both. Males were almost three times more likely than females to meet the criteria for alcohol abuse and/or dependence; however, the male-to-female ratio was lowest in the youngest age group among nonblack respondents, suggesting that the rates of these disorders in nonblack females may be catching up.

T his Epidemiologic Bulletin pre the first estimates of DSM-IV alcohol The NLAES featured a complex sents prevalence and population abuse and dependence to be reported at multistage design (Massey et al. 1989). estimates of alcohol abuse and the national level. Primary sampling units (PSU's) 1 were dependence in the United States stratified according to sociodemographic for the year 1992. The definitions for criteria and were selected with probability these alcoholrelated disorders were based BACKGROUND AND PROCEDURES proportional to size. Approximately 2,000 on the most recent criteria from the PSU's were in the 1992 NLAES sample,

Diagnostic and Statistical Manual of Mental
Prevalence and population estimates of 52 of which were selfrepresenting-that Disorders, Fourth Edition (DSM-IV) alcohol abuse and dependence were based is, selected with certainty. Within PSU's, (American Psychiatric Association [APA] on the 1992 NLAES, a nationwide house geographically defined secondary sam 1994). Prevalence defines the weighted hold survey sponsored by the National pling units, referred to as segments, were percentage of respondents classified with a Institute on Alcohol Abuse and Alcoholism DSM-IV diagnosis, and population esti (NIAAA). Field work for the study was selected systematically for each sample. mate refers to the number of people in conducted by the Bureau of the Census.
Oversampling of the black population the United States receiving a DSM-IV For the NLAES, direct facetoface inter was accomplished at this stage of sample diagnosis of alcohol abuse, alcohol depend views were conducted with 42,862 re selection. The decision to oversample the ence, or both. Oneyear prevalence esti spondents, 18 years of age and older, in black population was based on the higher mates were derived from selfreports of the contiguous United States and the observed rates of alcoholrelated disease symptoms of alcohol abuse and depen District of Columbia. The household (i.e., liver cirrhosis) in this group. dence on the 1992 National Longitudinal response rate for the NLAES was 91.9 Alcohol Epidemiologic Survey (NLAES). percent, and the personresponse rate was 1 For a definition of this term and others used in this The figures presented in this bulletin are 97.4 percent.
article, see glossary on p. 244.
Segments then were divided into clusters of approximately four to eight housing units, and all occupied housing units were included in the NLAES. Within each household, one randomly selected respondent, 18 years of age or older, was selected to participate in the survey. Oversampling of young adults, 18-29 years of age, was accomplished at this stage of the sample selection to in clude a greater representation of this heavy drinking population subgroup. This subgroup of young adults was sampled at a ratio of 2.25 percent to 1.00.
Because of the complex survey design of the NLAES, variance estimation proce dures that assume a simple random sam ple cannot be employed. Research has shown that clustering and stratification of the NLAES sample may result in standard errors much larger than those that would be obtained with a simple random sample of equal size. To take into account the NLAES sample design, all standard errors of the prevalence estimates presented here were generated using SUDAAN (Re search Triangle Institute 1994), a software program that uses appropriate statistical techniques to adjust for sample design characteristics.

DSM-IV CLASSIFICATION
The 1992 NLAES included an extensive list of questions designed to assess the presence of symptoms of alcohol abuse and dependence during the 12month BRIDGET F. GRANT, PH.D., PH.D.,   ited States technique that allows estimation of (e.g., cities) defined in terms of socio the amount of dispersion around a demographic criteria.

G L O S S A R Y
measure of data, such as a percentage or mean. Selected with probability: This typically refers to the selection of sampling Weighted percentage: Percentages that units according to predetermined have been adjusted to account for all probabilities. For example, primary aspects of the sample design (e.g., sampling units may be selected that differential rates of selection, over have probabilities proportional to size. sampling).
period preceding the interview. We devel oped these questions, in part, to opera tionalize the DSM-IV criteria for alcoholrelated disorders. Although the DSM-IV classification was not published until the second quarter of 1994, all of the specific diagnostic criteria for alcohol abuse and dependence were known prior to beginning the NLAES interviews (APA 1991) and therefore were incorporated into the final survey instrument in their entirety. What was not known prior to taking the NLAES into the field was which of the diagnostic criteria would be relegated to abuse and dependence cate gories. However, once all relevant DSM-IV diagnostic criteria were incorporated into the NLAES, computer algorithms could be designed to represent accurately the placement of the criteria within abuse and dependence categories consistent with the finalized diagnostic criteria. Correspond ence of the DSM-IV criteria with indi vidual NLAES questions is shown in the sidebar. According to DSM-IV, a diagnosis of alcohol abuse requires that a person exhibit a maladaptive pattern of alcohol use, leading to clinically significant impairment or distress, as demonstrated by at least one of the following: (1) con tinued use despite a social or interperson al problem caused or exacerbated by the effects of drinking; (2) recurrent drinking in situations in which alcohol use is physically hazardous; (3) recurrent drink ing resulting in a failure to fulfill major role obligations; or (4) recurrent alcohol related legal problems. A diagnosis of alcohol dependence requires that a person meet at least three of seven criteria de fined for dependence in any 12month period (see sidebar).
In the Diagnostic Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R) (APA 1987), the duration criteria associated with abuse and depend ence specify that some of the symptoms of the disorder must occur continuously during a month or repeatedly over a longer period of time. Unlike that of the DSM-III-R, the duration criteria of the DSM-IV abuse and dependence cate gories are associated with the individual diagnostic criteria and not the categories NIAAA's EPIDEMIOLOGIC BULLETIN NO. 35 of abuse and dependence per se. The shown in the sidebar, the duration criteria To satisfy the duration criterion for duration criterion for both alcoholrelated for abuse and dependence are not associ abuse, a respondent must have experienced disorders defines the repetitiveness with ated with all diagnostic criteria and are two or more symptoms of an abuse criteri which certain diagnostic criteria must defined by qualifiers, such as "recurrent," on associated with a duration qualifier at occur during a 12month period for these "often," and "persistent" desire or unsuc least once during the past year, or alter criteria to be considered positive. As cessful "efforts." natively, at least one symptom of that Similarly, to satisfy the duration crite rion for dependence, at least one symptom of a diagnostic criterion associated with a duration qualifier must have occurred at least twice over the course of the year preceding the interview, or alternatively, two or more symptoms related to these criteria must have occurred at least once during the same time period.
The diagnosis of dependence present ed in this bulletin was qualified further in an important way. Because the withdraw al criterion of alcohol dependence is defined in DSM-IV as a withdrawal syndrome (i.e., a cluster of symptoms), at least two symptoms of withdrawal, which met the duration criterion, had to occur during the past 12 months. It should be noted, however, that withdrawal is not required for a DSM-IV diagnosis of dependence. The DSM-IV diagnostic category for dependence could be speci fied further by evidence of physiological dependence (i.e., evidence of either toler ance or withdrawal, including drinking to relieve or avoid withdrawal) or no physio logical dependence (i.e., no evidence of tolerance and withdrawal). Table 1 presents the 1year prevalence rates, standard errors, and population estimates of DSM-IV alcohol abuse and dependence by age, sex, and ethnicity. The DSM-IV abuse and dependence groups formed by the 1992 NLAES were mutual ly exclusive. Respondents classified as alcohol abusers did not meet criteria for alcohol dependence; however, those who met criteria for dependence were classi fied as to whether they also met the criteria for alcohol abuse. Hierarchically, the DSM-IV does not allow a diagnosis of abuse in the presence of dependence, and thus all respondents classified in this bulletin as alcohol dependent with and without abuse would receive only a formal diagnosis of dependence. The purpose of disaggregating respondents classified as dependent with and without abuse merely was to provide more detail concerning the diagnostic status of respondents classified as alcohol dependent.

SUMMARY OF FINDINGS
The 1year prevalence of combined alcohol abuse and dependence in the NLAES sample was 7.41 percent, repre senting 13,760,000 Americans (table 1). Slightly more respondents were classified as alcohol dependent (4.38 percent) than as abusing alcohol (3.03 percent). Among those respondents meeting DSM-IV diag nostic criteria for dependence, the greatest proportion also met criteria for alcohol abuse. The predominance of the dual abusedependence diagnosis was generally consistent for each age, sex, and ethnic subgroup of the population. The majority of respondents with alcohol dependence diagnoses also were classified with physio logical dependence (4.25 percent) in con trast to no physiological dependence (0.13 percent) (data not shown).
Oneyear prevalence of alcohol abuse and dependence combined was much greater among males (11.00 percent) than females (4.08 percent). Prevalence also was greater among nonblacks (7.68 per cent) than among blacks (5.28 percent) (data not shown). Rates for nonblack males and females exceeded the rates for their black counterparts by 27.18 percent and 32.23 percent, respectively.
Prevalence rates of alcohol abuse and dependence were higher among respon dents under 45 years than among those 45 years or older, regardless of sex or ethnicity (table 1). For males, the preva lence rate in the youngest age group (18 to 29 years) was 22.07 percent. The rate decreased approximately 50 percent among 30to44yearold males (10.65) and was reduced to 1.18 among those 65 years and older. For females, the highest prevalence rate also was found in the youngest age group (9.84 percent), with the rates falling steadily to 0.27 percent in females 65 years and older. Possible explanations for the decline in alcohol abuse and dependence rates with age may include faulty recall accompanying in creasing age, lower survival rates among alcoholics, and various response styles. Alternately, the age gradient may reflect a true cohort effect; that is, that alcohol abuse and dependence are more preva lent among the younger generation of Americans.
Ethnic groups showed striking patterns of agerelated 1year prevalence rates of alcohol abuse and dependence (figure 1). Among the youngest males, the preva lence rate in nonblacks (23.48) was 1.9 times greater than in blacks (12.33). In the remaining age groups, the rates for non blacks and blacks converge, with a slight predominance among nonblacks. The patterns for nonblack and black females were similar to those of males, execept the black female rate exceeded the non black female rate among 30to64year old groups.
Although alcohol abuse and depend ence were greater among males than among females, there was evidence of convergence of the rates between the sexes in the youngest age groups (table  2). The maletofemale ratios (i.e., male rate divided by the female rate) were lowest in the 18to29yearold group. However, when the maletofemale ratio was examined separately for each ethnic group, it was clear that the rate converged among the youngest age groups only among nonblacks. In contrast, the maletofemale

Diagnostic Criteria For Alcohol Abuse
Diagnostic Criterion: Continued to drink despite social or interpersonal problem caused by drinking Questionnaire Item: • Continue to drink even though you knew it was causing you trouble with your family or friends.

Diagnostic Criterion: Recurrent drinking in situations where alcohol use is physically hazardous* Questionnaire Items:
• Drive a car, motorcycle, truck, boat, or other vehicle after having too much to drink. • Get into a situation while drinking or after drinking that increased your chances of getting hurt-like swimming, using machinery, or walking in a dangerous area or around heavy traffic.
Diagnostic Criterion: Recurrent alcoholrelated legal problems* Questionnaire Item: • Get arrested or held at a police station because of your drinking.
Diagnostic Criterion: Recurrent drinking resulting in failure to fulfill major role obligations at work, school, or home* Questionnaire Items: • Get drunk or have a hangover when you were supposed to be doing something important-like being at work, school, or taking care of your home or family. • Get drunk or have a hangover when you were actually doing something important-like being at work, school, or taking care of your home or family.

Diagnostic Criteria for Alcohol Dependence 1
Diagnostic Criterion: Tolerance 2 Questionnaire Items: • Find that your usual number of drinks had much less effect on you than it once did. • Find that you had to drink much more than you once did to get the effect you wanted. • Take a drink to get over any of the bad aftereffects of drinking. • Take a drug other than aspirin, Tylenol™, or Advil™ to keep from having a hangover or to get over the bad aftereffects of drinking. • Take a drink to keep from having a hangover or to make yourself feel better when you had one.
Diagnostic Criterion: Drinking larger amounts over a longer period of time than intended* Questionnaire Items: • Start drinking even though you decided not to or promised yourself you would not. • End up drinking more than you meant to. • Keep on drinking for a much longer period of time than you had intended to.
Diagnostic Criterion: Persistent desire or unsuccessful efforts to cut down or control drinking* Questionnaire Items: • Want to stop or cut down on your drinking. • Try to stop or cut down on your drinking but found you could not do it.
Diagnostic Criterion: Important social, occupational, or recreational activities given up or reduced in favor of drinking Questionnaire Items: • Give up or cut down on activities that were important to you in order to drink-like work, school, or associating with friends or relatives. • Give up or cut down on activities that you were interested in or that gave you pleasure in order to drink.
Diagnostic Criterion: Great deal of time spent in activities to obtain alcohol, to drink, or to recover from its effects Questionnaire Items: • Spend so much time drinking that you had little time for anything else.
• Spend a lot of time being sick or with a hangover from drinking.
• Spend a lot of time making sure that you always had alcohol available.
Diagnostic Criterion: Continued to drink despite knowledge of having a persistent or recurrent physical or psychological problem caused or exacer bated by drinking Questionnaire Items: • Continued to drink even though you knew it was making you feel depressed, uninterested in things, or suspicious or distrustful of other people. • Continued to drink even though you knew it was causing you a health problem or making a health problem worse.
*In order for the criterion to be positive, either: (a) two or more symptoms must have occurred at least once, or (b) one or more symptoms must have occurred at least twice during the past year.
1 Dependence diagnoses can be specified with physiological dependence (i.e., evidence of either tolerance or withdrawal) or without physiological dependence (i.e., no evidence of either tolerance or withdrawal). 2 Tolerance need have occurred only once during the past year for the criterion to be positive. 3 Two or more symptoms of withdrawal must have occurred at least twice during the past year for the criterion to be positive. ratio was much lower among blacks in the 30to64yearold groups. Thus, alcohol abuse and dependence were more preva lent in the younger age groups, particular ly among nonblack females.

DISCUSSION
More than 7 percent of adults surveyed met DSM-IV criteria for 1year alcohol abuse, alcohol dependence, or both. Males were almost three times more likely than females to meet the criteria for alcohol abuse and/or dependence. However, that the maletofemale ratio is lowest in the youngest age group among nonblacks suggests that nonblack females may be catching up. This phenomenon does not generalize to black females because the maletofemale ratios in blacks were shown to decrease as a func tion of age. Possible reasons for the greater discrepancy between male and female rates of alcohol abuse and depend ence among younger blacks compared with younger nonblacks include differen tial agerelated role responsibilities or differences in perceived social acceptabil ity of drinking per se between the ethnic groups in the general population. The overall prevalence estimates and corresponding population estimates of alcohol abuse and dependence presented here do not differ greatly from those for the years 1984 (Williams et al. 1989) or 1988 (Grant et al. 1991), even though these earlier figures were based on diag nostic criteria from the DSM-III (APA 1980) and the DSM-III-R, respectively. The prevalence of DSM-III alcohol abuse and dependence reported by the 1984 National Survey on Alcohol Use was 8.58 percent for the total sample, with an as sociated population estimate of 15,100,000. The corresponding DSM-III-R prevalence rate for the 1988 National Health Inter view Survey was 8.63 percent, represent ing 15,295,000 Americans. Although these figures are nearly identical to the prevalence of DSM-IV alcoholrelated disorders found in the 1992 NLAES sample, caution must be exercised in assuming the stability of these rates be tween 1984 and 1992. Because definitions of disorders differed among the three surveys, no conclusions can be made concerning the rates of alcohol abuse and dependence over time.
Although the purpose of this Epidemi ologic Bulletin is to present the national rates of alcohol abuse and dependence according to the most recent psychiatric classification of alcoholrelated disorders (i.e., the DSM-IV), provisions also were made within the NLAES to measure alcohol abuse and dependence by historic diagnostic classifications (i.e., the DSM-III and DSM-III-R). Representation of multiple definitions of alcoholrelated disorders will facilitate direct compar isons between the NLAES DSM-III estimates and the DSM-III estimates of the 1984 National Survey on Alcohol Use and between the NLAES DSM-III-R estimates and the DSM-III-R estimates derived from the 1988 National Health Interview Survey. It remains to be seen if trends exist over time in alcohol abuse and dependence. Such trends will become evident once the diagnostic definitions across these surveys are equalized. To this end, a series of reports focusing on trends in alcoholrelated disorders be tween the years 1984 and 1992 currently are being prepared by NIAAA. These reports will present, for the first time, changes in the rates for alcohol abuse and dependence over the last decade. ■